Form Au-738 - Motor Vehicle Fuels Tax Refund Claim - Nutrition Program
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1
2Department of Revenue Services
(For Drs Use Only)
Form AU-738
State of Connecticut
Excise Taxes Unit
Period of claim in calendar year
2013
Motor Vehicle Fuels Tax Refund Claim
25 Sigourney St Ste 2
Hartford CT 06106-5032
/
/
__ __
__ __ through __ __
__ __
Nutrition Program
(Rev. 06/13)
m
m
d
d
m
m
d
d
Connecticut Tax Registration Number
Refund claims must be fi led on or before May 31, 2014, for fuel used during calendar year 2013. You must
check the appropriate fuel type box at right. Complete this refund claim in blue or black ink only.
Federal Employer Identifi cation Number (FEIN)
Print name of claimant
Telephone number
Type of business
(
)
Social Security Number (SSN)
Number and street
Check if change of address
Fuel type:
Diesel
City or town
State
ZIP code
Motor vehicle fuels (gasoline-gasohol)
Claim type:
Nutrition program
Location of records if different from above
Schedule A - Statement of motor vehicle fuel purchases: Receipts must be attached. Attach additional sheet(s) as necessary to provide a
complete response.
Date
Name of Supplier
Gallons of Fuel
Date
Name of Supplier
Gallons of Fuel
Total:
Round to the nearest whole gallon.
You must attach a copy of your contract with your local area agency on aging as evidence of your eligibility to provide
Title III-C meals to senior citizens.
Schedule B - Computation of net refund
1.
Total miles for period
1.
2.
Total fuel gallons for period: Enter the total number of fuel gallons from Schedule A.
2.
3.
Average miles per gallon: Divide Line 1 by Line 2; carry to .0001.
3.
4.
Total miles in delivery vehicles used exclusively for the delivery of meals to senior citizens
4.
5.
Refund gallons: Divide Line 4 by Line 3.
5.
6.
Tax refund claimed: Multiply Line 5 by _______ per gallon. See Refund Rates on reverse.
6.
$
00
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is
true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a fi ne of not more than $5,000, imprisonment for not more than fi ve years,
or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
Taxpayer signature
Title
Date
Print taxpayer’s name
Telephone number
Email address
(
)
Print preparer’s name
Preparer’s SSN or PTIN
Email address
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